Which Muscle Relaxant do you prefer to prescribe?

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Blitz2006

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Just wondering, as the pain doc I work with likes baclofen, but psychiatrists that prescribe it tend to swing towards Robaxin. I don't see much of Flexiril either?

Any good papers you recommend on muscle relaxants?
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I like baclofen, can work for oddball pain issues. If you have a patient who's pain is so weird you are thinking of low dose narcan, try Baclofen first. Cheap, very well tolerated.

I don't use is just for muscle issues. Use it for lots o' stuff.
 
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Ligament said:
I like baclofen, can work for oddball pain issues. If you have a patient who's pain is so weird you are thinking of low dose narcan, try Baclofen first. Cheap, very well tolerated.

I don't use is just for muscle issues. Use it for lots o' stuff.
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Do you find it safe in your clinical experience, with regards to side effects? Again in psych, we are brainwashed that baclofen is a 'dirty' drug.
 
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Blitz2006 said:
Do you find it safe in your clinical experience, with regards to side effects? Again in psych, we are brainwashed that baclofen is a 'dirty' drug.
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It works on gaba right? I think it's safe. Just titrate slowly and advise patients they may experience sedation, drowsiness, lethargy etc. If they stop make sure to taper off otherwise they may have seizures
 
None .
Followed by robaxin.
 
My usual order is zanaflex, baclofen, flexeril, robaxin. Never a benzo or Soma (soma + benzo + opioid = the "holy trinity" on the street). I stay away from drug cocktails with street names...
 
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Good luck getting Zanaflex approved
 
Soma and Xanax, all day, every day:)
 
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I think the better question is how long does one prescribe muscle relaxants. Days, weeks, months?
 
Stim4me said:
I think the better question is how long does one prescribe muscle relaxants. Days, weeks, months?
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Forever. As part of a multimodal well rounded regimen. No evidence that I'm aware of though. If anyone has evidence please share.
 
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They have no evidence for long term use, but everyone ends up using long term....


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What about in the case of liver/kidney dysfunction?
 
Cyclobenzaprine helps with centralized pain I thought I read somewhere. I even use it on the FM patients. Everybody gets it. Yummy. Tizanidine is second on list. I consider Robaxin similar to Soma in it's tranquilizing properties so I advise against it (is that wrong?). Baclofen rarely. Studies have compared (in ER though I think) Naproxen and Cycloenzaprine vs Naproxen alone and there was no difference. But whatever.. it'll get ya drunk (Chappelle show)
 
Papa Lou said:
Cyclobenzaprine helps with centralized pain I thought I read somewhere. I even use it on the FM patients. Everybody gets it. Yummy. Tizanidine is second on list. I consider Robaxin similar to Soma in it's tranquilizing properties so I advise against it (is that wrong?). Baclofen rarely. Studies have compared (in ER though I think) Naproxen and Cycloenzaprine vs Naproxen alone and there was no difference. But whatever.. it'll get ya drunk (Chappelle show)
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That's bc cyclobenz is basically a tca. Ie not the best to use on older patients, cardiac issues or anybody on serotonin acting medication


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The only difference between cyclobenzaprine and amitriptyline is one double bond. Both are TCA and are used interchangeably with each other in times of shortages.
 
Taus said:
That's bc cyclobenz is basically a tca. Ie not the best to use on older patients, cardiac issues or anybody on serotonin acting medication


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Agree with taus and algos. I treat flexeril like a TCA as well.

I only disagree with serotonin medications. Risk of serotonin syndrome is remote unless on high doses of both meds. I don't worry about 10-25mg QHS of a TCA in someone on a standard low dose of a SSRI.

That said, I'll try other muscle relaxants first if someone is on SSRI.
 
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Papa Lou said:
I consider Robaxin similar to Soma in it's tranquilizing properties so I advise against it (is that wrong?).
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Yes, that's wrong. Soma metabolizes to meprobamate. Robaxin does not



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oddly enough, i find that it is hard to get robaxin (or generically, methocarbamol) around here - most insurances require prior auth, particularly with tizanidine.

this, for a drug available OTC in Canada...
 
Ducttape said:
oddly enough, i find that it is hard to get robaxin (or generically, methocarbamol) around here - most insurances require prior auth, particularly with tizanidine.

this, for a drug available OTC in Canada...
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Cash price for Robaxin is $15 for a month's supply
 
Taus said:
That's bc cyclobenz is basically a tca. Ie not the best to use on older patients, cardiac issues or anybody on serotonin acting medication


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On the otherhand, if the patient has pain that is being amplified by central factors, it is a terrific med for exactly the same reason!
 
Ducttape said:
Good to know. Your point?

Lest you forget, a majority of my patients rely on the SNAP program. $15 may be 1/6 of their entire disposable income for the month.


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$50 cell phone
$75 cigarettes
$15 Robaxin
$15 Norco
$90 McDonalds

$245 spent - $90 =$155

They are taking bid Norco 10mg and selling 1 per day to pay the rest of their budget.
 
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Sorry to bump this, as I didn't want to make a new thread. New fellow here, frustrated by the data-free nature of attending preferences for these drugs. For whatever reason we are a tizanidine institution, which as I understand is the only drug in that class with a modicum of evidence. Otherwise, how did you all select your relaxant of choice? Seems all made up save for certain issues re: renal clearance, flexeril in old patients etc, no soma.

This is an entire drug class that seems like a collective black box to me..
 
Norepi said:
Sorry to bump this, as I didn't want to make a new thread. New fellow here, frustrated by the data-free nature of attending preferences for these drugs. For whatever reason we are a tizanidine institution, which as I understand is the only drug in that class with a modicum of evidence. Otherwise, how did you all select your relaxant of choice? Seems all made up save for certain issues re: renal clearance, flexeril in old patients etc, no soma.

This is an entire drug class that seems like a collective black box to me..
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If one has side effects or doesn’t work try a different one.

If you want to zonk out an acute radic at bedtime give flexeril. Don’t want any grogginess or sedation give robaxin or baclofen. In the middle than give tizanidine.
 
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dipriMAN said:
If you want to zonk out an acute radic at bedtime give flexeril. Don’t want any grogginess or sedation give robaxin or baclofen. In the middle than give tizanidine.
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Haha. My thoughts exactly!
 
If you want 5 star reviews give carisoprodol
 
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Mostly trial and error, everybody reacts to different ones differently.

Robaxin usually my go to, as usually not sedating, high therapeutic index, cheap.

Tizanidine and baclofen next. Both seem more sedating than Robaxin, tizanidine theoretically can either liver enzymes.

Flexeril usually just sedating but many have tried previously and if it worked I'll refill.

Seldomly will try Skelaxin or orphenadrine if failed above.
 
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lot of prescriptions for drugs that don't work....
 
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Norepi said:
Sorry to bump this, as I didn't want to make a new thread. New fellow here, frustrated by the data-free nature of attending preferences for these drugs. For whatever reason we are a tizanidine institution, which as I understand is the only drug in that class with a modicum of evidence. Otherwise, how did you all select your relaxant of choice? Seems all made up save for certain issues re: renal clearance, flexeril in old patients etc, no soma.

This is an entire drug class that seems like a collective black box to me..
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It's a black box for everyone really, but here is a quick old paper:
pubmed.ncbi.nlm.nih.gov

Choosing a skeletal muscle relaxant - PubMed

Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

and a more recent, quick book chapter on it
www.pmr.theclinics.com

Muscle Relaxants for Acute and Chronic Pain

Utilization of muscle relaxants varies for treatment of acute and chronic pain. This article provides an overview of the different types muscles relaxants and their adverse effects. Appropriate medication selection based on clinical indications is also examined.
www.pmr.theclinics.com
 
Here is my algorithm.

If the patient says nothing, my prescription is nothing.

If the patient says “x has helped me in the past”, I write x (unless it is Soma).

On RARE occasion I will try Tizanidine.

Otherwise, I’m not sure why a drug would somehow know which muscle it needed to relax and leave all the other functional muscles alone.
 
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Robaxin during the day - least sedating
Tizanidine at bedtime - ( believe it is more sedating then flexeril) Patients seem to find this one works very well
I don't use much baclofen or flexeril. Have NEVER prescribed soma (though interestingly, robaxin is related)
 
Remember that, with the exception of baclofen, none of them have direct effect on the muscles themselves.

Even baclofens main location of action is CNS and spinal cord.

There is no good science for muscle relaxation as these meds don't really relax muscles.
 
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Skelaxin least sedating followed robaxin

I anecdotally hear flexeril is most sedating followed by tizanidine

Orphenadrine is basically Benadryl and flexeril is basically a TCA
 
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